Helen Ann Halpin

Effects of Asthma Education on Children's Use of Acute Care Services: A Meta-analysis

OBJECTIVE. National Heart, Lung, and Blood Institute clinical practice guidelines strongly recommend that health professionals educate children with asthma and their caregivers about self-management. We conducted a meta-analysis to estimate the effects of pediatric asthma education on hospitalizations, emergency department visits, and urgent physician visits for asthma. PATIENTS AND METHODS. Inclusion criteria included enrollment of children aged 2 to 17 years with a clinical diagnosis of asthma who resided in the United States. Pooled standardized mean differences and pooled odds ratios were calculated. Random-effects models were estimated for all outcomes assessed. RESULTS. Of the 208 studies identified and screened, 37 met the inclusion criteria. Twenty-seven compared educational interventions to usual care, and 10 compared different interventions. Among studies that compared asthma education to usual care, education was associated with statistically significant decreases in mean hospitalizations and mean emergency department visits and a trend toward lower odds of an emergency department visit. Education did not affect the odds of hospitalization or the mean number of urgent physician visits. Findings from studies that compared different types of asthma education interventions suggest that providing more sessions and more opportunities for interactive learning may produce better outcomes. CONCLUSIONS. Providing pediatric asthma education reduces mean number of hospitalizations and emergency department visits and the odds of an emergency department visit for asthma, but not the odds of hospitalization or mean number of urgent physician visits. Health plans should invest in pediatric asthma education or provide health professionals with incentives to furnish such education. Additional research is needed to determine the most important components of interventions and compare the cost-effectiveness of different interventions.

Importance of Adult Literacy in Understanding Health Disparities

AbstractBACKGROUND: In several recent studies, the importance of education and race in explaining health-related disparities has diminished when literacy was considered. This relationship has not been tested in a nationally representative sample of U.S. adults. OBJECTIVE: To understand the effect of adult literacy on the explanatory power of education and race in predicting health status among U.S. adults. DESIGN: Using the 1992 National Adult Literacy Survey, logistic regression models predicting health status were estimated with and without literacy to test the effect of literacy inclusion on race and education. SUBJECTS: A nationally representative sample of 23,889 noninstitutionalized U.S. adults. MEASURES: Poor health status was measured by having a work-impairing condition or a long-term illness. Literacy was measured by an extensive functional skills test. RESULTS: When literacy was not considered, African Americans were 1.54 (95% confidence interval, 1.29 to 1.84) times more likely to have a work-impairing condition than whites, and completion of an additional level of education made one 0.75 (0.69 to 0.82) times as likely to have a work-impairing condition. When literacy was considered, the effect estimates of both African-American race and education diminished 32% to the point that they were no longer significantly associated with having a work-impairing condition. Similar results were seen with long-term illness. CONCLUSIONS: The inclusion of adult literacy reduces the explanatory power of crucial variables in health disparities research. Literacy inequity may be an important factor in health disparities, and a powerful avenue for alleviation efforts, which has been mistakenly attributed to other factors.

Rethinking Prevention in Primary Care: Applying the Chronic Care Model to Address Health Risk Behaviors

This study examines the Chronic Care Model (CCM) as a framework for preventing health risk behaviors such as tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity. Data were obtained from primary care practices participating in a national health promotion initiative sponsored by the Robert Wood Johnson Foundation. Practices owned by a hospital health system and exhibiting a culture of quality improvement were more likely to offer recommended services such as health risk assessment, behavioral counseling, and referral to community-based programs. Practices that had a multispecialty physician staff and staff dieticians, decision support in the form of point-of-care reminders and clinical staff meetings, and clinical information systems such as electronic medical records were also more likely to offer recommended services. Adaptation of the CCM for preventive purposes may offer a useful framework for addressing important health risk behaviors.

Chronic Disease Prevention and the New Public Health

Chronic diseases are the major causes of morbidity and mortality across the globe in developed and developing countries, and in countries transitioning from former socialist status. Chronic diseases — including heart disease, cancer, stroke, diabetes, and respiratory diseases — share major risk factors beyond genetics and social inequalities including tobacco use, unhealthy diet, physical inactivity, and lack of access to preventive care. There are evidence-based interventions that are effective in modifying these risks and subsequently preventing disease. Evidence for prevention is strongest for measures aimed at reducing tobacco use and increasing physical activity, while large gaps remain in our knowledge about how to effectively change eating habits and achieve healthy weights in a population. The New Public Health addresses interventions delivered at three levels: 1) at the level of society, where public policy and governmental interventions can change the environment, as well as individual behavior (e.g., regulation of tobacco products and food composition, taxation, redesigning the built environment, banning advertising); 2) at the level of the community, through the activities of local institutions delivered at the population level (e.g., school-based and workplace health promotion, community education, training, and public awareness campaigns); and 3) at the level of the individual, through the provision of clinical preventive services including screening, counselling, chemoprophylaxis, and immunizations (in recognition of the growing evidence that infections cause important chronic diseases). We conclude with a discussion of comprehensive national and international efforts needed to stem the tide of the growing global burden of chronic disease.

Medicaid Provider Delivery of the 5A's for Smoking Cessation Counseling

This paper assesses rates of the 5As (ask, advise, assess, assist, and arrange) of brief provider counseling received by Medicaid-enrolled smokers and recent quitters and the differences in receipt of counseling as a function of age, gender, race, ethnicity, and health status. A random sample telephone survey was conducted among Medicaid-enrolled smokers and recent quitters in four geographic areas in the United States. Multivariate logistic regression models estimated the relationships between demographic characteristics and delivery of the 5As. Less than 10% of Medicaid smokers and recent quitters reported receiving all 5As. Medicaid providers delivered the ask, assess, and advise components of smoking cessation counseling to the majority of their patients who were smokers or recent quitters. However, they were much less likely to provide comprehensive counseling, with fewer than 25% of patients reporting receiving any assistance with quitting (i.e., a prescription for pharmacotherapy or referral to counseling) or arrangement of a follow-up visit or phone call. Receipt of the 5As varied as a function of health status, race, and ethnicity. Medicaid needs to (a) increase provider delivery of the full spectrum of counseling interventions recommended for smoking cessation and (b) extend provider outreach to the demographic groups that receive the lowest rates of counseling.

Hospital adoption of automated surveillance technology and the implementation of infection prevention and control programs

BACKGROUND This research analyzes the relationship between hospital use of automated surveillance technology (AST) for identification and control of hospital-acquired infections (HAI) and implementation of evidence-based infection control practices. Our hypothesis is that hospitals that use AST have made more progress implementing infection control practices than hospitals that rely on manual surveillance. METHODS A survey of all acute general care hospitals in California was conducted from October 2008 through January 2009. A structured computer-assisted telephone interview was conducted with the quality director of each hospital. The final sample includes 241 general acute care hospitals (response rate, 83%). RESULTS Approximately one third (32.4%) of Californias hospitals use AST for monitoring HAI. Adoption of AST is statistically significant and positively associated with the depth of implementation of evidence-based practices for methicillin-resistant Staphylococcus aureus and ventilator-associated pneumonia and adoption of contact precautions and surgical care infection practices. Use of AST is also statistically significantly associated with the breadth of hospital implementation of evidence-based practices across all 5 targeted HAI. CONCLUSION Our findings suggest that hospitals using AST can achieve greater depth and breadth in implementing evidenced-based infection control practices.

So near, yet so far: Tobacco dependence treatment for pregnant women

Almost one-half million babies in the United States are born yearly to women who report smoking while pregnant. Almost all of these pregnant women have access to prenatal care, through federally financed health clinics, state and county health programs, or private providers. However, many pregnant smokers are unlikely to receive any type of counseling or assistance to help them stop smoking--despite the availability of evidence-based treatment and the considerable return on investment. This article recommends four next steps to ensure that tobacco dependence treatment is available for all pregnant women. These steps are (a). expanding Medicaid coverage for, and promotion of, effective counseling services for pregnant smokers, (b). improving health care systems by building the capacity of prenatal providers and health care systems to deliver effective treatments, (c). encouraging purchasers of private and public health benefit packages to demand coverage for, and promotion of, effective counseling services for pregnant smokers, and (d). redirecting state resources to ensure a statewide system of care for pregnant smokers. Implementation of these steps requires leadership, diligence, and action by the public health community--as well as ongoing monitoring to assess progress in improving coverage, capacity, and coordination.

Trends in Employer-Sponsored Health Insurance Coverage for Tobacco-Dependence Treatments

BACKGROUND Nearly 1.8 million smokers in California receive their health insurance benefits through their employer. The extent to which these workers have coverage for tobacco-dependence treatments (TDTs) through their employer-sponsored health care is unknown. METHODS This research used the 2000 and 2005 data from the California Employer Health Benefits Surveys to determine coverage for TDTs by private firms. The overall response rates of firms to the survey were 41% and 36%, respectively. The samples used in this analysis are limited to private firms in California that offered employee health benefits in 2000 (n=729) or in 2005 (n=745). RESULTS This research found that among private firms offering health insurance coverage, there was a significant increase from 2000 to 2005 in the percentage of workers covered for any TDTs (44% to 57%). Rates of coverage for all three forms of TDTs (nicotine replacement therapy, Zyban, counseling) doubled from 11% to 22% over the 5-year time period. CONCLUSIONS Although coverage levels have improved, they still fall short of the recommendations made in the U.S. Public Health Service guidelines as well as in the Healthy People 2010 objectives. Given the effectiveness, cost effectiveness, public demand for coverage, and relatively low cost of covering TDTs--estimated to be

Mandatory Public Reporting Of Hospital-Acquired Infection Rates: A Report From California

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Adoption of System Strategies for Tobacco Cessation by State Medicaid Programs

6 per member per year--it is difficult to understand why such coverage is not more widely available in California.